The efficacy of non-pharmacological interventions on internalising symptoms associated with ADHD

Home | The efficacy of non-pharmacological interventions on internalising symptoms associated with ADHD

30 Jun 2019

López-Pinar C et al. J Atten Disord 2019; Epub ahead of print

ADHD in adulthood is commonly associated with internalising symptoms, including mood and anxiety disorders (Kessler et al. 2006). Non-pharmacological treatments such as cognitive behavioural therapy (CBT), cognitive training (CT), cognitive hypnotherapy, dialectical behavioural therapy (DBT), mindfulness-based therapies (MBTs), neurofeedback (NFB) and psychoeducation (PsyEd) have been evaluated in adults with ADHD. These therapies have had mixed success in reducing internalising symptoms in adults with ADHD. This meta-analytic review aimed to evaluate the efficacy of these different non-pharmacological interventions (specifically adapted or developed to address the core symptoms of ADHD in adults) for treatment of comorbid internalising symptoms (depression and anxiety symptoms, low self-esteem, impaired perceived quality of life [QoL] and emotional dysregulation [ED]). This study also sought to investigate if the effect of treatment on core ADHD symptoms could predict improvements on comorbid internalising symptoms.

A literature search* was conducted to identify studies with ≥1 experimental group receiving a non-pharmacological intervention specifically designed or modified for treating adult ADHD. From 1054 study records, 20 randomised control trials (RCTs), three controlled pre-test–post-test studies and 12 uncontrolled single-group pre-test–post-test studies were selected.† A total of 1389 study participants were randomised across the RCTs examined; among these, data were collected from 1163 participants post-treatment and from 629 participants at follow-up. Across the uncontrolled studies selected, 634 participants were initially included in the pre–post studies, 521 were maintained at post-treatment and 219 at follow-up. Participants were mostly male (51.85%), mean age was 34.16 years, and 54.79% of participants were taking medication for ADHD.

Overall, 41.67% of participants had CBT (n = 15), 16.67% had DBT and MBT (n = 6 each), 13.89% had NFB (n = 5), 5.56% had CT (n = 2), and 2.87% had hypnotherapy or PsyEd (n = 1). The average length of the interventions was 12.34 sessions. Treatments were given in either group (48.47%) or individual (36.36%) sessions, or as a combination of both (15.15%). Self-reported measures were most commonly used to assess efficacy, although blinded (3.12%) and un-blinded (10.91%) independent assessors were used in some studies.

CBT did not have a significant effect on self-esteem when control and treatment groups were compared; however, a small-to-moderate post-treatment within-subject ES (SMD 0.62; 95% CI 0.31–0.92; I2 = 80%) increased to large at follow-up (SMD 1.404; 95% CI 0.45–1.64; I2 = 74%).

This study had several limitations. Firstly, PsyEd and hypnotherapy interventions were each only examined in one study with a small sample size (n = 9). Secondly, variations in study design and sample size may limit the appropriateness of direct comparison of efficacy of these studies. Thirdly, the small number of studies in some subgroups could limit the statistical power of the analyses used to identify predictors of improvements on internalising symptoms. Fourth, merging all of the therapy modalities may have limited the findings regarding how these variables may influence the effect of each intervention. Fifth, there were a small number of studies that compared the treatment with active control groups, which may limit the specificity of the psychotherapies assessed. Sixth, the inclusion of uncontrolled studies may impair internal validity, as this impacts on the control of other variables and could influence the observed effects. Finally, the generalisability of these findings may be limited due to the high heterogeneity observed in some post-treatment outcomes.

The authors concluded that this systematic review offers support for the efficacy of non-pharmacological treatment, notably CBT, in treating comorbid internalising symptoms in adults with ADHD. CBT achieved better improvements in comorbid anxiety and depression symptoms, as well as long-term QoL and ED outcomes compared with waiting list and treatment-as-usual groups. The authors advocated the use of these therapies as part of comprehensive treatment of adult ADHD.

*The databases Scopus, PsycINFO and MEDLINE were searched by terms relating to adult ADHD, CBT, DBT, neurofeedback and MBT. The following terms where used in the title and abstract: adult*, ADHD OR attention deficit hyperactivity OR psychosocial t* OR skills train*, CBT OR cognitive behavio, DBT OR dislectical behavio, neurofeedback, MBCT OR mind-ful*. The last search was performed on 20 October 2018†Studies with participants aged ≥18 years with a primary diagnosis of ADHD made by a mental health professional (either in the community or by a member of the study research team) on the basis of a full clinical interview and ADHD rating scales were included. Studies with participants with severe active addictions, bipolar, psychotic or personality disorders were excluded from the analysis. RCTs with an active control group (e.g. participants were given support by a therapist but no specific strategy was discussed, non-specific interventions for ADHD such as relaxation OR sham NFB may be used); or a treatment-as-usual control group (all participants received ADHD medication and perhaps some counselling or clinical management, provided no specific strategy was discussed); or a waiting list control group (participants were waiting without receiving a non-pharmacological intervention) were eligible for inclusion. Uncontrolled single-group pre-test–post-test studies were also included

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